good evening and welcome to doctors on call I'm Dr Ray Christensen a faculty member from the Department of Family Medicine and biobehavioral health at the University of Minnesota medical school here on the Duluth campus I'm also a family physician at the Gateway Family Health Clinic in Moose Lake I am your host for our program tonight on end of life remember the success of doctors on call is still very dependent on you the viewer so please call in your questions tonight or email them to ask at pbsnorth.org the telephone numbers can be found at the bottom of your screen this evening we are privileged to have panelists again people that have been here with this problem before and a new person also Dr Jeff coatman is a family physician with the Fairview misaba Clinic in Hibbing and Dr coltadine welcome back to the area a long-term care specialist with Essentia Health our medical students answering the phones tonight are Sophie Brown from Fairmont Minnesota Joseph dimelo of Minneapolis and Melissa Edgar from Kasson Minnesota and now on to our program on end of life gentlemen we talked earlier about this one of the things that I've always struggled with in practice and I still don't do it probably like I should is we always are trying to treat things and make people better and our work in medicine is always to a cure or to having things get better and and resolve is there a time in practice when we should start talking to people about end of life and why don't we do that and Jeff you're the expert a little bit on this sure um I don't think there's there's you know there's not like a definite number you know at age 50 age 40 whatever A lot of it depends on what you have as far as underlying medical conditions go and the other thing is um talking with your family members before making everything legal so to speak and so I've been involved in several cases where Advanced directors may not have been done but we were able to get a direction as to what to do in end of Life Care um because they had to talk to their family members that made their wishes known in general when I was in primary care I started having patients at least thinking about it at age 40. um but we really didn't do all the you know the formal things but to start planting that seed how did you do that I usually it was part of our routine physical and I said have you ever thought about Advanced directives if something happens you're in an accident have you talked to your family about what you would want done and uh that usually got the wheels turning and and um to thinking about advance directives Dr Dean again welcome back to Northeast Minnesota thank you really nice to have you back uh your practice at the present time is geriatric medicine can you tell me a little bit about your practice so now I work half as a hospitalist and half as a geriatrician and much of that work is in Transitional Care so patients who have been in the hospital for this or that and are not able to go directly home but need a period of convalescence and additionally I have a long-term care practice at various facilities and so these conversations about not just end of life but what to do with certain medical scenarios arises at the heart of my work now and before this practice I did I had a primary care practice for six or seven years and similar we I would 40s 50s start to Broach those conversations and at the heart of it I think these are important things for people to think about and address oh what phrase to use while firing on all cylinders so to speak before some time of Crisis comes up before that time of Crisis comes is the time to have those conversations that's true Jeff I neglected to ask you what you are doing at the present time I was interested in our topic but what are you what's your practice like nowadays um right now I'm basically geriatrics in in hospice and palliative medicine I was trained in family medicine and practiced primary care for 30 years and now I'm exclusively geriatrics in in hospice care I'm the medical director of our hospice and also the medical director of four nursing homes in the area so you guys are well placed for this so I'm 40 years 50 years old where do I start what's the first thing that I should be thinking about as I approach end of life are we talking post POS teas living wills take me down the road someplace here where would you like to start my general approach is in those clinics settings to start with an advanced directive and many different clinics have something like that that lays out various potential scenarios and multiple different options for how would the person want that approached with some room to put in specific person-centered details that might not be one of the regular options there the very first question though is if a person were unable to make medical decisions themselves who would they want doing that for them and to have something like that in place and communicated with that other person is is I think at the heart of those other decisions that can be laid out in our practice where we have something called honoring choices honorary choices that's the one I was trying to remember honoring choices yeah and what that is is basically um it's like a living will and basically what it does addresses exactly what you want um should you become a number one com becoming capacitated number two as far as your care goes if you become very sick the difference between you had mentioned the post and and that's a that's something that's relatively new and the reason that um well first of all we'll back up what the pulse is is basically it stands for physician orders for life-sustaining treatment and the difference between that and in advance directive is that the pulse is actually of Physicians order because if you have an advanced directive and it is not available to anybody you cannot be made to do not resuscitate in general unless it's a physician's order so this way if you have a pulse sign it's either in the home at the facility and so that's actually an order so if you have a do not resuscitate on your post no heroic Measures will be done the other thing I might um comment on on the honoring choices is that um as coltis said first of all you have we look for a medical power of attorney and that's someone to make decisions for you should you become incapacitated but another part of that is something called the DNR dni and there's oftentimes a lot of confusion as to what that actually means we go through that quite often and in a lot of patients think that if they're signing a DNR DNA that means we don't do anything if they become ill and and that really isn't the truth what it what a DNR dni means is that if you pass away we don't do anything to bring you back it does not mean that we don't treat things up until that point and and a lot of times patients don't understand that and they won't they won't sign that even though they're very severely ill and if you become incapacitated we go with the advanced directives to your medical power of attorney and if they're not available we go to next of kin Etc there's a whole process to go through to help with end-of-life care post you may want to post Colt you may want to add into this too but one of the other questions that just came through is who should get a pulsed a polst so why don't you add on and give us your thoughts essentially everybody who's admitted to a nursing home in Minnesota will have one of those filled out as as part of that process but my own approach is in in patients who may only have a year or a short amount of time left to go through that and to perhaps make some of those delineations and care if there isn't a full advance directive in place and if there are specific orders that are needed it's a fairly simple to work through form without many of the other complex decisions in a formal advance directive in in my world um like Colt said we have all of the patients that are in skilled nursing facilities will have a pulse everyone that's on our hospice service will have a pulsed and also we have uh we've been doing a fair amount of home-based palliative care and a pulse a lot of times will be done in those patients too so if if you have a pulsed and you have a DNR or a dni and you're living in the community what happens when the ambulance shows up well that's the that's a very good question that's one of the reasons why we came up with the post is that we recommend uh at least ours inhibiting is on a colored envelope and it's on the refrigerator and so that when an ambulance is called to go into the home that's the first place they look and also we have it scanned into the medical record so should they come to the emergency room but I suppose they get the medical record in the ambulance nowadays too without yeah with cell phones yes Colt at what point should a person consider hospice if I have a patient and they are their whole medical status is such that I would not be surprised if if they were deceased in six months then they're a hospice candidate and um if a person isn't has a medical scenario where they either do not have other options for medical treatment and have a terminal illness or don't want to keep toiling that path for many various reasons then hospice becomes reasonable so how do you determine six months there are so many different parts of that it it at the heart of it is clinical judgment meeting with knowing the patient knowing what underlying ailment or ailments they might have interconnected with how they've responded to different treatments and experience together you know if I could could please comment also on that is um when you look at hospice the one thing that is not definite is prognosis meaning that everybody's body is different in all diseases behave differently in that particular person so when we're looking at people that may qualify for Hospice we're looking at the whole picture we look at the six months or less we look at statistics and so all that goes into prognosis now medicine is not an exact science and so um when we admit somebody to hospice that's our best guest that they have six months or less to live and that's usually certified by two Physicians one being their primary and one being the hospice physician but what we've had patients that actually graduate from hospice that's how inexact the science can be that patients actually do better than we expected and then we will discharge them and if their illness progresses we will readmit them to our Hospice Services there's a couple of questions that come in one is are there people that you work with that are hospice managers if you will or Hospital hospice doulas are these people that you either one of you work with as you work with hospice we don't have we don't have any in in the hospice that I work with at all but I've heard of that that term I'm familiar with the Doula from from a birth standpoint and I have not worked with hospice doulas per se but the combination of hospice supports and we can talk about what comes with hospice later on in the program that remarkable team functions as doulas in a sort with that death transition as that comes well this might be a good time to talk about what comes with hospice so why don't you just continue one of you go ahead in your your hospice directorship role right um so hospice one of the the things that uh that uh patients often get confused with they tend to think of hospice as a place and hospice really isn't a place it's a um it's a concept of care and so and when we look at hospice we look at the entire patient it's not just dealing with pain dealing with shortness of breath those kind of things but we deal with psychosocial issues spiritual issues all that that involve the total care of the patient and so when somebody's on hospice our patients are taken care of by a hospice team which entails a lot of different Specialties not only the physician but we have nursing staff we have Pharmacy we have chaplain we have social work we have home health aides all of that all of us work to together to take care of the hospice patients so it's more than just symptom management and it's not a place it's a concept and they the the Hospice team will meet with the patient in their home if they're at a nursing home if they're in a and and sometimes there's a hospice specific facility yes but the hospice team will meet with the people wherever they're at they don't generally accept her in some specific facilities provide 24 7 care correct but they they provide they they augment and help the the family and whatever other health care services might be in play what about the routine Medical Care at that time is that all then delivered by hospice at home or or are they do they end up in hospitals too and the people that are in hospice you know the if I could if I could comment yeah help me with that because my memory is that that you you stay home right in that and that is when we when we admit somebody to hospice and we look at us we always look at the goals of care and when we know someone has a terminal illness we try not to use the hospital um there's a certain circumstance though when we will um for instance if someone in the home setting or in the facility setting is having intractable symptoms meaning pain is uncontrolled shortness of breath is uncontrolled um pain from bowel obstructions we will admit to the hospital for a short period of time under hospice to get symptoms controlled and then eventually transition back at home so our goal is to not have hospitalization because um when patients are in hospice the reason they would go into something that's not reversible an exception to that is if somebody's on hospice for lung cancer and they fall and break their hip that's a whole different issue it's not related to the terminal diagnosis so oftentimes we will discharge from hospice until that is taken care of and then readmined Colt how do you prepare a family for the impending death of a loved one to begin with at that point I I've spent time to get to know the patient and their family their history their story what different trials and tribulations and it everybody's so different every family is so different and it it's so it's so unique to the individual but I I will talk about first what are what do they know about the underlying disease process where do they think things are are going at that point what do they think the next plan of action is what do they want to do what are their hopes and expectations for what time they have left and to get some idea of how much time they have left and then have a conversation together with the players and the play to both discuss prognosis and to discuss multiple options going forward in a in a fluid conversation and if I might uh big time that one of the things that we've run into in in Hospice Care is that a lot of times we're not called early enough a lot of times the patients are very very ill they call us in to help us symptom management and I'm a very firm believer that the earlier that hospice is involved the better prepared the patient and the family is for the impending death in in quote that is basically I'm not in my head very much so yes so when we're involved and we have chaplains we have social workers we have nurses that get there it's it's it's much easier to help prepare them for the impending death so how do I how do you get me as a physician to be thinking hospice I think one of the things that we get caught up in the delivery of care are there things that we need to do better in thinking about hospice and moving toward that what would you say to your colleagues each both of you you're an internist Primary Care docs I think at the same time if most of us at the same time need to be both the resuscitation doctor and the Comfort measures doctor and different scenarios different degrees and to have one's blinders on Purely and in one direction for all scenarios is is it just it's not the reality of of of of our work and I think just to have an awareness that if if a person's prognosis is such and that that hospice system is an option to start to Broach that possibility and to know the patient to know how best to talk about such things and we encourage our um you know like to back up a little bit um our hospice referrals are not only just from Physicians they are from families and they're from members of the community about patients they may know and the nursing staff and the nursing and to be honest with you a lot from the nursing staff and so anybody can refer to hospice and we've tried um to make a concerted effort for partners to to think about us if there's any question about the complexity of the disease or any question about things that they cannot fix um we're very blessed up on the ranges that we have a home-based palliative care program and what palliative care is it's not hospice care but palliative care is starting if hospice is the last six months of Life palliative care is like the last two years of life and we're starting to get more involved in the palliative care part in people that have ill chronic illnesses that aren't fixable so to speak they're going to progress and we make that transition into hospice and we're getting more referrals for palliative care I Miss Amy greminger because that's the area to discuss and make it better Amy yes I'd like to Quick interject one thing I found very helpful for patients especially who are leaving the hospital they're not sure if they would like to pursue hospice or not is to arrange a home informational hospice visit where they meet members of their their local hospice team and they might not sign up for it at that point but they know they know them they become familiar and they're able to get that information and so if they decide to elect that hospice benefit in the future it's easier and more familiar yep so we this is a question that I think has come up for all of us at one point another if a person has no one no family no one to speak for them no one to represent them is there someone within the medical system who can make decisions for them help them make decisions and who would they who they could put into an advanced directive would that be an ombudsman or what what do you do in those situations so we we run into that situation periodically in the hospital and then it is that most institutions have their own institutional process that works for those people who do not have a next of kin or some other friend or other person who who who's able to help with those decisions and it usually goes to a couple of Physicians a number of Physicians or other people in in in in the group where they they run things by each other and it takes verification and working working with the patient as well if they have the capacity to give some of their thoughts and desires about things then of course that's that's he leaned heavily upon but different systems have a process and we have in the in the car in St Louis County we have a designated um person who actually is maybe assigned by the judge to be the power of attorney for a patient that does not have the X-Men we have to get the judge in that's right yep and that's legal and then they make the decisions for them tough question we gotta talk about we've got four minutes at the end of life why can't people act access a physician-assisted suicide in the United States and how much do doctors consider patients Desiring euthanasia so it's a tough question this is Minnesota do you want to you want to address this a little bit it's not legal in the state and I have yet to have a patient myself request that um in my world yes we have we call it the request for a hasten death and um it's that's from a physician's standpoint that's a very very difficult thing to address with patients I mean the first thing that I always say like quote says is number one is it's not legal in Minnesota it is in other states but number two is that we get torn because we know the patient is terminal we know they're in our goal as Physicians is to relieve suffering but we have ways that is not assisted suicide to relieve pain and suffering we can control 90 percent of pain 95 percent of pain and other symptoms that occur an end of life 95 year old Mammoth and Mi why don't Physicians just let them pass away if he doesn't have a good chance of recovery what does recovery mean and what does that person's quality of life uh many times a a heart attack or myocardial infarction in in these days if there's a 98 blockage and a stent is placed then the heart muscle Downstream of that often remains viable and functional it it all depends on all depends on the clinical scenario but before any such procedure is done the cardiologist or the other Hospital team will have conversations with that patient and their family about what would you want to do would you want to do these things and so autonomy is so important do you have situations where a spouse has a DNR and the spouse doesn't know about it or where a person has a DNR and the spouse doesn't know about it it's a question that came in so apparently this happens I have had some I've had a couple of scenarios where one spouse did have that filled out and in conversation it became apparent that the other did not know and then we had a conversation about that and what that meant afterward do you provide support for the caregivers also in hospice yes yes and one of the nice things about that and that's a very intimate part of our practice is support for the caregivers we also have a bereavement program and we follow our family members for up to a year after the death of the patient on hospice we've got about a minute left any closing comments that you'd like to make I just it's so important to think about some of these things Advanced Directive Etc when a person is firing on all cylinders Do It preemptively Strike do it think about think about it every week I work in the hospital I see a patient who hasn't had those conversations with their family members and their family members often struggle with with the weight of that yep I guess the other part of that is reminder physician ask your physician physician and bring it up we need to be part of that with you I want to thank our panelists this evening Dr Jeff Coleman and Dr coladine and our medical student volunteers Sophie Brown Jeff Demello and Melissa Edgar please join me next week for a program on diabetes with my panels will be Dr Dave Hutchinson Dr Jason wall please thank you for watching have a great night foreign